Break the fracture cycle

Every year, millions of patients at U.S. hospitals are admitted and successfully treated
for osteoporotic fractures. “A shoulder, a pelvis, a hip—those patients
typically are fixed nicely by orthopedics,” said Ethel Siris, MD, an endocrinologist
and professor of medicine at Columbia University in New York.

But then things fall apart. “There is no medical follow-up with instructions
about calcium and vitamin D or with prescription medication, which virtually all of
these older patients need,” said Dr. Siris. “Most of these people are
at very high risk of more fractures in the next year or two, yet they are not given
the medications they need to prevent the next fracture.”

Photo by Thinkstock.

Research has found rates of osteoporosis treatment in these patients to be as low
as 10% or 20%, in fact. “The rates are appalling,” said Barbara Lukert,
FACP, an endocrinologist and professor of internal medicine at the University of Kansas
in Kansas City. The percentages of fracture patients who are screened for osteoporosis
are similar.

Such low rates have been the norm for years, but the impetus for improvement may soon
become a little more urgent. “The Joint Commission is pilot testing a measure
that would assure if you're 65 and older and you get admitted with a fracture, either
a bone density test or some medication is given within 90 days,” said Dr. Siris.
Preventing fractures may also be of interest to accountable care organizations, given
the associated high cost, morbidity and mortality.

Because of hospitalists' position as leaders in inpatient quality improvement and
as comanaging clinicians, they may be ideally placed to improve fracture prevention
efforts. Osteoporosis experts offered their thoughts on how hospitalists, orthopedists
and other team members can raise treatment rates from appalling to acceptable.

Why so hard?

Compared to many of the tasks accomplished in the hospital, osteoporosis diagnosis
and treatment seem simple. “That's a few simple blood tests to look for secondary
disease states and a quick review of the patient's medicines to make sure this isn't
somebody on steroids or other medications that negatively affect bone,” said
Dr. Siris.

Treatment typically involves a prescription for bisphosphonates (either oral or intravenous;
see sidebar) and recommendations or a prescription for calcium and vitamin D. “Calcium
and vitamin D are usually not covered on insurance because they're over-the-counter
medications, but at least if you have a written prescription, that's a reminder to
the patient that they ought to go out and buy some of this stuff,” said Donald
Morrish, MD, an endocrinologist and professor at the University of Alberta in Canada.

But a number of common obstacles prevent this process from being completed, beginning
with communication between specialties. “Orthopedics takes responsibility for
fixing the fracture. And there is not yet the appropriate mechanism, as crazy as it
sounds, to get these people appropriately referred to medicine people who will take
responsibility for the medical management,” said Dr. Siris.

Even in hospitals where hospitalists are called to consult on elderly fracture patients,
preventive treatment may fall through the cracks. “[The patients] often have
multiple illnesses and are on all sorts of different drugs. Many of the illnesses
are perceived as more immediately threatening. So the osteoporosis gets forgotten
as drug #15 on the list,” said Dr. Morrish.

And, last but certainly not least, money is an issue. A recent review of interventions
to improve osteoporosis treatment in fracture patients, published online in May by Osteoporosis International, found one trait that was associated with greater success: staff who worked specifically
on this effort. “It makes a difference if you've got somebody who has a dedicated
role,” said study author Joanna Sale, PhD, assistant professor in the department
of health policy, management and evaluation at the University of Toronto in Canada.

A common model of dedicated staffing is the fracture coordinator, “usually
a nurse or a nurse practitioner who works with the cooperation of orthopedics and
medicine to make sure that [for] every inpatient who's had a fracture and anybody
who comes to the ER with a fracture…blood tests are done for vitamin D levels
and things like that,” described Dr. Siris.

The fracture coordinator's job doesn't end with discharge. An intervention that Dr.
Morrish conducted called the position a care manager, but the job was similar. “Someone
went up and contacted the patients [before and after discharge] and basically mothered
them along and made sure that they went and got bone densities,” he said. “It
usually took six or seven phone calls to nag people to get out and have your bone
density done.”

The persistence paid off. In Dr. Morrish's study, published in Archives of Internal Medicine in October 2007, case managers brought the rates of osteoporosis treatment up to 51%
and bone density testing to 80%, compared to 22% and 29% in a control group receiving
usual care.

Siris's hospital found success with its similar program. “The fracture coordinator
makes it work. The problem right now is who pays the salary of the fracture coordinator,”
she said. “We don't have the money to pay the coordinator. It only works when
we have funds from a grant.”

On the inside

Given the unreimbursed costs of dedicated staff, other hospitals have experimented
with alternative methods of increasing osteoporosis treatment, with varying degrees
of success.

“One of the efforts that's been made in the past that has been a complete failure
has been for the orthopedics people to say, ‘We're going to write a letter
to your doctor saying you broke a hip and that you need something to be done about
it,’” said Dr. Siris.

Morrish tried a more intensive variation on that concept, in which bone density tests
were conducted on fracture patients and the results, along with current guidelines
on osteoporosis treatment, were sent to their primary care physicians. The effort
substantially improved treatment rates, but not to researchers' satisfaction. “If
one leaves it to other people to do these things, there's multiple reasons I'm sure
why the osteoporosis therapy doesn't get started,” Dr. Morrish said.

The alternative, of course, is to do the job oneself. Handing out prescriptions for
osteoporosis medication in the hospital resulted in twice as much use as contacting
outpatient physicians, Dr. Morrish found. “We didn't leave it to chance with
the orthopedic surgeon or the family doctor,” he said.

If the process is reduced to just writing a script, orthopedists could potentially
take care of that. “In fact, in our region, the orthopedic surgeons…have
agreed that what gets written on the orders of every patient after hip surgery is
that they get put on generic alendronate,” said Dr. Morrish.

Not all orthopedists will be keen on that plan, though, according to Dr. Lukert. “Orthopedists
don't want to prescribe because they're not going to follow these people long-term
and it probably would be inappropriate for them to prescribe it, because one of the
important things is that we are sure the patient gets evaluated for other causes of
osteoporosis,” she said.

There was some debate among the experts about how much evaluation is necessary, for
example, whether a bone density test is a prerequisite to a prescription. “There's
probably 10% to 20% [of hip fracture patients] that actually don't have low bone density.
But it could be argued that they still have osteoporosis causing a fragility fracture,”
said Dr. Morrish.

Whether the evaluation process involves a bone-density test or not, it's turned out
to be a job for hospitalists at some facilities. Hospitalists and orthopedic surgeons
at the Mayo Clinic in Jacksonville, Fla., got together to create a comanagement program
in which the hospitalists did preoperative evaluations on fracture patients and at
the same time screened them for osteoporosis.

The intervention increased evaluation for osteoporosis among hip fracture patients
from 24% to 89%, according to results published in Clinical Orthopaedics and Related Research in March 2011. “The bottom line is you want to play to the strengths of the
members on your team,” said orthopedic surgeon and study author Mary O’Connor,
MD. “We certainly weren't achieving our goals with orthopedic surgeons being
responsible for doing this.”

The Mayo program has found continued success with its model, but a similar program
at the University of Kansas Medical Center fell apart after the hospitalist leader
moved on to another hospital. “We had a pretty good program working for a while,”
said Dr. Lukert. “It's just hard to keep somebody interested in doing that
forever.”

Electronic medical records may provide the means to convert osteoporosis screening
from an interesting project to a regular habit.

“Our hospitals use a computer system, so if a hospitalist admits somebody with
a hip fracture, they have a hip fracture template they use,” said Michael Herson,
MD, chief of endocrinology at Northwest Permanente Medical Group in Portland, Ore.
“It automatically orders vitamin D levels when the patient's admitted. It automatically
orders a bisphosphonate to be given at the time of discharge unless the computer systems
pick up an intolerance or a contraindication.”

Morrish also supported this idea. “I think there's an opportunity for the hospitalist
with a care map to mechanize the process so that it happens to everybody and it's
not left to chance,” he said.

Potentially, once it's mapped out, the task could even be delegated to non-physicians.
“The hospitalist's primary role it seems to me is to be a champion on the inpatient
side for making sure not only are we clearing this person for surgery, but are we
making an assessment of this patient's medical status, calcium, vitamin D?”
said Dr. Siris.

And on that subject, she has one more little request for hospitalists. “If
somebody comes in with a GI bleed, and the hospitalist says, ‘I'm going to
take a medical history,’ one of the things the hospitalist should be asking
is ‘Have you ever had a bone density test?’…and…’Since
the age of 50, have you broken a bone?’” Dr. Siris said. “I don't
know whether hospitalists are going to be willing. But the older patient who is at
risk would benefit if somebody took responsibility.”

Treatment choices

Screening fragility fracture patients for osteoporosis and providing a prescription
is only half the battle in preventing future fractures. To be effective, the medication
also has to be taken by the patient.

The risk of that process not coming to completion makes zoledronic acid, the yearly
intravenous drug, an appealing alternative to oral medication. “We would love
to use that rather than the alendronate, because it sort of guarantees at least one
year of treatment,” said Donald Morrish, MD, an endocrinologist and professor
at the University of Alberta in Canada.

However, the IV drug comes with its own obstacles. Dr. Morrish is unable to use it
because the Canadian health care system doesn't cover it, and cost is an issue in
the U.S., too. “It costs about 1,600 bucks. If you give it while the patient
is in the hospital, it cuts into the DRG [diagnosis-related group], and the hospitals
don't like that,” said Ethel Siris, MD, an endocrinologist and professor of
medicine at Columbia University in New York.

Her hospital has found a way around that issue, although it's contingent on co-location
of the treating physicians. “When you come back for your first orthopedic follow-up,
that's an outpatient visit,” she said. “First, see the orthopedic surgeon
and then you're going to go two flights up to the medicine department…we can
give you the infusion then.”

Teripratide and denosumab are two other effective therapy options, Dr. Siris noted.
“Alendronate, which is generic and not expensive, and other bisphosphonates—IV
is very useful in these patients—are first line, but the other two agents turn
out to be valid alternatives in certain patients,” she said.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.